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Brief Reports
1996;22 (June)
Leukopenia and Thrombocytopenia in a Patient with
Early Lyme Borreliosis
Lyme disease, a multisystemic infection caused by the tickborne spirochete Borrelia burgdorferi [1], has recently been associated with a single case of leukopenia and thrombocytopenia [2].
We report the case of a patient with documented early Lyme
borreliosis, leukopenia and thrombocytopenia, and elevated liver
enzyme levels.
In August 1995 a 22-year-old man who had previously been
healthy developed fever, headache, myalgia, arthralgia of the knees
and elbows, conjunctivitis, fatigue, and an erythematous area on
the right thigh; this lesion was .--.3 cm in diameter. One week
earlier he had been camping in forests in Slovenia but did not
remember being bitten by a tick. Four days after the onset of
symptoms, he returned to Switzerland and consulted the emergency
unit of our hospital. He had not taken any medication for at least
a half year and had no risk factors for HIV infection.
Physical examination revealed a temperature of 39.6°C and a 5
X 7-cm erythematous oval lesion with partial central clearing typical of erythema migrans (EM), on the lateral side of the right
thigh. The lymph nodes were not enlarged, and no signs of arthritis
were found. Findings ofthe neurological examination were normal.
No electrocardiographic abnormalities were noted.
Significant laboratory values were as follows: WBC count, 2.2
X 109/L (neutrophil count, 1,3 X 109/L [47% band forms and
12.5% segmented cells]; 26.5% lymphocytes [lymphocyte count,
0.6 X I09/L]; 11,5% monocytes; 0.5% eosinophils; and 2% basophils). Morulae were not identified on review of the peripheral
blood smear. Other laboratory values were as follows: platelet
count, 98 X 109/L; hemoglobin, 158 giL; erythrocyte sedimentation rate, 4 mmIh; C-reactive protein, 59 mglL (norrnallevel, < 10
mg/L); serum aspartate aminotransferase, 96 UIL (normal level,
<40 UIL); serum alanine aminotransferase, 91 U/L (normal level,
<40 U/L); serum lactate dehydrogenase, 580 UIL (normal level,
<460 U/L); and partial thromboplastin time, 72% (normal, 70%100%). Cultures of two blood samples drawn 1 hour apart before
antibiotic treatment was started yielded no bacterial growth.
A screening test (relative fluorescence; VIDAS Lyme, bioMerieux, Marcy L'Etoile, France) was used for detecting IgG and IgM
antibodies to B. burgdorferi. Relative fluorescence values were
as follows: <0.75, negative; 0.75-1.00, borderline; and > 1,00,
positive. Western blot analysis was performed to confirm the diagnosis; for a positive result, a minimum of five bands, including
three bands of the 93-kD antigen (pIOO), flagellin, p39, outer surface protein A (Osp A), and outer surface protein C (Osp C), had
to be present. For a borderline result, five bands, including only
two of the specified bands, had to be present. The relative fluorescence values of the screening test were 0.44 on day zero (day
patient presented at hospital), 1.2 one week later, and 2.6 three
weeks later. The western blot analysis on day zero showed a
weakly positive reaction of serum IgM antibodies to B. burgdorferi
(six bands showing specific reactions to flagellin, p39, and Osp
C) and a borderline result for IgG antibodies (five-to-six bands
showing a specific reaction to flagellin and p39).
One week later, a strongly positive reaction of IgM (10 visible
bands showing a specific reaction to flagellin, Osp C, Osp A, and
p39) and a weakly positive reaction of IgG (eight visible bands
showing a specific reaction to flagellin, p39, and Osp C) were
observed. Three weeks later, the reactions of both IgM and IgG
antibodies were clearly positive (more than 10 bands were visible
for each).
Serological tests for IgG antibodies to Ehrlichia equi (the antigen was provided by Dr. 1. S. Dumler, University of Maryland,
Baltimore) and Ehrlichia phagocytophila and for IgG and IgM
antibodies to tick-borne encephalitis virus, which were performed
on days 7, 21, and 90, were negative. These results are consistent
with seroconversion during early Lyme borreliosis. The patient
was treated with doxycycline (100 mg bj.d.) for 3 weeks. His
fever resolved 24 hours after the initiation of treatment, the EM
disappeared, and all laboratory parameters became normal when
treatment was stopped.
Our patient presented with fever, arthralgia, myalgia, headache,
conjunctivitis, fatigue, slight hepatitis, and EM-the typical symptoms and signs of early Lyme borreliosis. Seroconversion was
documented by the serological screening test and confirmed by
western blot analysis. Leukopenia and thrombocytopenia have not
been described in large studies of Lyme disease [4-6]. In one
study [4], 24 (8%) of 314 patients with early Lyme disease who
were tested had elevated leukocyte counts with shifts to the left
in the differential counts. A review of the literature revealed the
case of a 19-year-old woman with agranulocytosis and thrombocytopenia that were caused by infectious-toxic bone marrow damage
[2]. Because EM was not present, the diagnosis ofLyme borreliosis
was delayed. The levels of IgG and IgM antibodies to B. burgdorferi were elevated, but they dropped after she was treated with oral
ampicillin. In another published case, the patient had hepatitis due
to recurrent Lyme disease, which was associated with isolated
thrombocytopenia [7].
Our patient, as well as the two previously described in the
literature, fully recovered after receiving adequate antibiotic treatment. Hypothetically, our patient could have been infected by
another tick-borne infectious agent in addition to B. burgdorferi
[8]. Ehrlichial diseases in humans often cause leukopenia and
thrombocytopenia [9, 10]; however, the negative serological test
result nearly rules out the possibility of a coinfection with an
Ehrlichia species in our patient. These three cases show that leukopenia and thrombocytopenia can occur in both early and recurrent
Lyme disease. Lyme borreliosis should therefore be added to the
list of infectious diseases that can cause leukopenia and thrombocytopenia.
Huldrych F. Giinthard, Olivier Peter, and Jacques Gubler
Reprints or correspondence: Dr. Huldrych Gtinthard, Virology and Infectious
Diseases Section, Departments of Pathology and Medicine 0679, University
of California, San Diego, 9500 Gilman Drive, La Jolla, California 920930679.
Clinical Infectious Diseases
1996;22:1119-20
of Chicago. All rights reserved.
1058--4838/96/2206-0041 $02.00
© 1996 by The University
Department of Internal Medicine, Stadtspital Triemli, Zurich; and
Institut Central des Hopitaux Valaisans, Sian, Switzerland
Acknowledgments
The authors thank Dr. Ph. Brouqui, World Health Organization
Collaborative Center for Rickettsial Reference and Research, Fa-
1120
culte de Medecine, Marseille, France, for testing the serum samples
for Ehrlichia equi and Dr. M. Brossard, Laboratoire de Diagnostic
Parasitaire, Neuchatel, Switzerland, for performing the serological
tests for Ehrlichia phagocytophila and for tick-borne encephalitis
virus.
References
I. Steere AC, Grodzicki RG, Kornblatt AN, et al. The spirochetal etiology
of Lyme disease. N Engl J Med 1983;308:733-40.
2. Kamp T, Zink C, Beer C, Kaboth W, Nerl C. Agranulozytose durch
infektios-toxische Knochenmarkschiidigung nach Borrelien-Infektion.
Dtsch Med Wochenschr 1995; 120:636-40.
3. Peler 0, Marini M, Blanc E, Dupuis G. Le diagnostic de la borreliose de
Lyme. Schweiz Med Wochenschr 1991;121:189-93.
The Role of Human Herpesvirus 8 and Epstein-Barr
Virus in the Pathogenesis of Giant Lymph Node
Hyperplasia (Castleman's Disease)
Castleman's disease (CD) is a rare nonneoplastic lymphoproliferative disorder of unknown etiology. Two distinct histopathologic
variants of CD have been described [1]: the hyaline vascular type,
presenting as a tumorlike mass in the mediastinum or retroperitoneum, and the rarer plasma cell type, typically characterized by
generalized lymphadenopathy, immunologic abnormalities, and
type B symptoms suggestive of a systemic viral infection. Patients
with generalized CD of the plasma cell type (but not those with
hyaline vascular CD) are at increased risk for Kaposi's sarcoma
(KS) and lymphomas, including Epstein-Barr virus (EBV)-associated immunoblastic lymphoma of B cells and Hodgkin's disease [2).
Both KS and a restricted group of lymphomas in patients with
AIDS have been closely linked to the presence of a novel BIymphotropic gammaherpesvirus [3-5], provisionally named
KSHV or human herpesvirus 8 (HHV-8) [6]. DNA sequences of
this virus were also found in lymph node biopsy specimens with
pathological features similar to those of CD that were obtained
from HIV-infected patients, most of whom had, or subsequently
had, KS [7]. In the same study, however, specific DNA sequences
of HHV-8 were found in only seven of 17 biopsy specimens from
mY-negative patients with CD.
To investigate whether HHV-8 could be implicated in the pathogenesis of CD, we tested six biopsy specimens from mY-negative
patients with CD (four with the plasma cell type and two with
the hyaline vascular type) by PCR analysis and Southern blot
hybridization with primers and probes specific for HHV-8 [3],
EBV [8], and .a-globin. Lymph node biopsy specimens from 15
HIV type I-infected drug abusers with persistent generalized
lymphadenopathy and five mY-negative patients with reactive
Reprints or correspondence: Dr. Carlo Parravicini, Servizio di Anatornia 00
Istologia Patologica, Ospedale "L. Sacco," via G. B. Grassi, 74, 20157 Milan,
Italy.
Clinical Infectious Diseases 1996;22:1120-1
© 1996 by The University of Chicago. All rights reserved.
1058-4838/96/2206-0042$02.00
cm
Brief Reports
1996;22 (June)
4. Steere AC, Bartenhagen NH, Craft JE, et al. The early clinical manifestations of Lyme disease. Ann Intern Med 1983;99:76-82.
5. Asbrink E, Olsson I, Hovrnark A. Erythema chronicum migrans Afzelius
in Sweden. A study on 231 patients. Zentralbl Bakteriol Mikrobiol Hyg
[Aj 1986;263:229-36.
6. Sigal LH. Summary of the first 100 patients seen at a Lyme disease referral
center. Am J Med 1990;88:577-81.
7. Goellner MR, Agger WA, Burgess JH, Duray PH. Hepatitis due to recurrent Lyme disease. Ann Intern Moo 1988; 108:707-8.
8. Aeschlimann A, Burgdorfer W, Matile H, Peter 0, Wyler R. Aspects
nouve,lUx du role de vecteur joue par Ixodes ricinus L. en Suisse. Acta
Trop 1979;36:181-91.
9. Dumler JS, Bakken JS. Ehrlichial diseases of humans: emerging tick-borne
infections. Clin Infect Dis 1995; 20: 1102-1 O.
10. Fishbein DB, Dawson JE, Robinson LE. Human ehrlichiosis in the United
States, 1985 to 1990. Ann Intern Med 1994; 120:736-43.
lymphadenitis were included in the study as controls. DNA from
an HHV-8-positive KS lesion and tubes without DNA (9] were
used as positive and negative internal controls, respectively. None
of the patients had, or subsequently had, KS or lymphoma in the
year following biopsy.
Lymph node samples and controls were processed in parallel
according to the protocol of a 35-cycle PCR amplification starting
with 500 ng of DNA obtained by proteinase K digestion, phenolchloroform extraction, and ethanol precipitation. Strict measures
were followed throughout the entire procedure to monitor the occurrence of false-positive results [10].
DNA sequences of HHV-8 were detected by PCR analysis in
all biopsy specimens from patients with plasma cell CD, while
both biopsy specimens from patients with hyaline vascular CD
and control lymph node biopsy specimens were negative. By contrast, EBV was found in only two biopsy specimens frOID patients
with plasma cell CD and two biopsy specimens from HIV-infected
patients with persistent generalized lymphadenopathy; all other
biopsy specimens were negative. By limiting dilution, semiquantitative PCR analysis revealed striking differences in the HHV-8
and EBV loads in patients with plasma cell CD. In particular,
Case
no.
I
~-Globln
HHV-I
EBV
II~==II=======
•
II~~II--
Plasma cell
4
I•
5
I.S~=l-11'----_ _II_ _ IHyall';';~ascu'ar
type
Figure 1. Results of limiting dilution semiquantitative PCR analysis of DNA extracted from patients with the plasma cell type (cases
I and 4) and the hyaline vascular type (case 5) of Castleman's disease.
Note the strong positivity for human herpesvirus 8 (HHV-8) in both
cases of plasma cell Castleman's disease, as opposed to Epstein-Barr
virus (EBV), which is present in only case 4. Before PCR analysis,
DNA was serialIy diluted 10-fold from 500 ng to 0.05 ng. Amplifications were performed with specific primers for human .a-globin, EBV
[8], and HHV-8 [3], as described previously. Amplimers were analyzed on 1.5% agarose gels, transferred onto nylon membranes, and
hybridized with 32P-labeled oligomer probes.